Presentation
Knee twisting injury accompanied by a pop during a volleyball game.
Patient Data
Age: 15 years
Gender: Female
From the case:
Multi-ligament injury of the knee
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Findings:
Extensive knee joint effusion
Intercondylar region:
- abnormal orientation, disruption and discontinuity of the anterior cruciate ligament (ACL) fibers
- focal fluid visible between the anterior cruciate ligament and the lateral femoral condyle in the intercondylar notch
Medial compartment:
- bone contusion at the posterior medial tibial plateau
- normal meniscus
- tearing of the anterior part of the joint capsule and the deep portion of the medial collateral ligament (MCL) or medial meniscofemoral ligament
- a tear of the posterior oblique ligament (POL)
Lateral compartment:
- bone contusions at condylopatellar sulcus of the lateral femoral condyle and the posterior lateral tibial plateau
- unremarkable cartilage and lateral meniscus
- visible Wrisberg meniscofemoral ligament with a Wrisberg pseudo-tear
- anterior and posterior, inferior popliteomeniscal fascicles not readily definable and small lesion of the lateral aspect of the superior popliteomeniscal fascicle
Patellofemoral compartment:
- high signal of the femoral attachment of the medial patellofemoral ligament (MPFL)
- unremarkable retro-patellar and trochlear cartilage
- medial patellar plica
Impression:
- rupture / high-grade tear of the anterior cruciate ligament with bone bruises at typical locations
- partial tear of the medial collateral ligament
- low-grade posteromedial corner injury
- partial medial patellofemoral ligament tear of the femoral origin
- a suspected small tear of the popliteomeniscal fascicles
- extensive knee joint effusion
From the case:
Multi-ligament injury of the knee
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Anterior cruciate ligament tear:
- abnormal orientation, disruption and discontinuity of the anterior cruciate ligament (ACL) fibers (red arrows)
- focal fluid visible between the anterior cruciate ligament and the lateral femoral condyle in the intercondylar notch also referred to as the empty notch sign (red arrowhead)
- bone contusions at the condylopatellar sulcus also known as deep lateral femoral notch sign (orange arrow) and at the posteromedial and posterolateral tibial Plateau (orange arrowheads) as an expression of a pivot-shift injury
Associated injuries:
- tearing of the anterior part of the joint capsule and the femoral portion of the medial meniscocapsular ligament (blue arrow)
- tearing of the posterior oblique ligament (blue arrowhead)
- sprain of the tibial semimembranosus tendon insertion (purple arrowhead)
- a small longitudinal meniscal tear of the posterolateral border of the lateral meniscus at the insertion of the posterosuperior meniscopopliteal fascicle (purple arrow)
Case Discussion
This case illustrates MRI findings in multi-ligament knee injury:
- a complete anterior cruciate ligament (ACL) tear
- medial collateral ligament injury with a tear of the deep portion anteromedial joint capsule and meniscofemoral ligament
- injury of the posterior oblique ligament
- partial tear of the femoral origin of the medial patellofemoral ligament
- bone bruises at the condylopatellar sulcus and the posteromedial and posterolateral tibial plateau
- a small longitudinal meniscal tear of the posterolateral border of the lateral meniscus at the insertion of the posterosuperior meniscopopliteal ligament
The patient was treated with bracing for 6 weeks and delayed anterior cruciate ligament reconstruction. The medial ligamentous structures were after those 6 weeks intraoperatively stable and not further inspected. The small longitudinal meniscal tear of the posterolateral border of the lateral meniscus at the insertion of the posterosuperior meniscopopliteal fascicle was confirmed and repaired.